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Research Article Prevalence of Anemia among Older Adults Residing in the Coastal and Andes Mountains in Ecuador: Results of the SABE Survey Carlos H. Orces Laredo Medical Center, Department of Medicine, 1700 East Saunders, Laredo, TX 78041, USA Correspondence should be addressed to Carlos H. Orces; [email protected] Received 10 December 2016; Revised 29 January 2017; Accepted 6 February 2017; Published 21 February 2017 Academic Editor: Francesc Formiga Copyright © 2017 Carlos H. Orces. is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objectives. To estimate the prevalence of anemia and its determinants among older adults in Ecuador. Methods. e present study was based on data from the National Survey of Health, Wellbeing, and Aging. Hemoglobin concentrations were adjusted by participants’ smoking status and altitude of residence, and anemia was defined according to the World Health Organization criteria (<12 g/dL in women and <13 g/dL in men). Gender-specific logistic regression models were used to examine the association between demographic and health characteristics and anemia. Results. A total of 2,372 subjects with a mean age of 71.8 (SD 8.2) years had their hemoglobin measured, representing an estimated 1.1 million older adults. e crude prevalence of anemia was 20.0% in women and 25.2% in men. However, higher anemia prevalence rates were seen with advancing age among black women and subjects residing in the urban coast. Likewise, certain health conditions such as hypoalbuminemia, cancer in men, chronic kidney disease, iron deficiency, and low grade inflammation were associated with increased odds of having anemia. Conclusions. Anemia is a prevalent condition among older adults in Ecuador. Moreover, further research is needed to examine the association between anemia and adverse health-related outcomes among older Ecuadorians. 1. Introduction Anemia is a common medical disorder in older adults associated with increased risk of functional impairment, hospitalization, and mortality [1, 2]. In general, the prevalence of anemia increases with advancing age and is higher among men and black populations [3]. Gaskell et al. reported that the mean prevalence of anemia among older adults in developed countries was 12% in community-dwelling older adults, 40% in hospital admissions, and 47% in nursing homes residents [4]. Previous studies have documented that the etiology of anemia in older adults appears to be multifactorial, with nutritional anemias, chronic kidney disease, and chronic inflammation found in two-thirds of the cases and unex- plained anemia of aging in one-third of the cases [3, 5]. While the prevalence of anemia has been described in children and women of reproductive age in Ecuador, there is scarce epidemiological data about this condition in older adults [6]. In the 1980s, a study conducted by Ca˜ nizares et al. described that the crude prevalence of anemia was 21% among 2,652 subjects aged 2 to 75 years in Ecuador. Notably, the prevalence of anemia differed considerably according to areas of the country. In fact, 30.2% of subjects residing in rural areas were classified as having anemia as compared with 4.1% of those from urban areas of the country [7]. Moreover, life expectancy has gradually increased in Ecuador over the past decades. For instance, Ecuadorians were expected to live 64.6 years in 1980–1985 and will reach 78.3 years by 2025–2030 [8]. ese demographic changes may increase considerably the number of individuals at risk for anemia in the country. erefore, this study aimed to estimate the prevalence of anemia in a nationally representative sample of adults aged 60 years and older. 2. Material and Methods e present study was based on data from participants in the first National Survey of Health, Wellbeing, and Aging Hindawi Current Gerontology and Geriatrics Research Volume 2017, Article ID 4928786, 10 pages https://doi.org/10.1155/2017/4928786

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  • Research ArticlePrevalence of Anemia among Older AdultsResiding in the Coastal and Andes Mountains in Ecuador:Results of the SABE Survey

    Carlos H. Orces

    Laredo Medical Center, Department of Medicine, 1700 East Saunders, Laredo, TX 78041, USA

    Correspondence should be addressed to Carlos H. Orces; [email protected]

    Received 10 December 2016; Revised 29 January 2017; Accepted 6 February 2017; Published 21 February 2017

    Academic Editor: Francesc Formiga

    Copyright © 2017 Carlos H. Orces. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

    Objectives. To estimate the prevalence of anemia and its determinants among older adults in Ecuador.Methods. The present studywas based on data from the National Survey of Health, Wellbeing, and Aging. Hemoglobin concentrations were adjusted byparticipants’ smoking status and altitude of residence, and anemia was defined according to theWorld Health Organization criteria(

  • 2 Current Gerontology and Geriatrics Research

    (Encuesta Nacional de Salud, Bienestar, y Envejecimiento)conducted between 2009 and 2010. This survey is a prob-ability sample of households with a least one person aged60 years or older residing in the Andes Mountains andcoastal regions of Ecuador. In the primary sampling stage,a total of 317 sectors from rural areas ( 200 ng/mL serves to confirm that anemia is not relatedto iron deficiency [15, 16]. Consequently, older adults withthese ferritin cut-off levels were classified as having irondeficiency anemia and anemia of chronic disease, respec-tively. Creatinine clearance (CrCl) was calculated accordingto the Cockroft-Gault equation and subjects with a CrCl< 30mL/min were classified as having anemia of chronickidney disease [3, 17]. In the present analysis, a CRP level ≥5mg/L was the cut-off used to define low grade inflammation[18]. Vitamin B

    12deficiency was defined as serum B

    12levels

    < 200 pg/mL and hypoalbuminemia as a serum albuminconcentration < 3.5 g/dL [3, 19].

    2.4. Statistical Analysis. Chi-square for categorical variablesand 𝑡-test for continuous variables were used to comparethe characteristics of the participants by gender. The crudeprevalence of anemia stratified by sociodemographic andhealth characteristics of participants and the MCV distribu-tion according to selected causes of anemia were presentedas percentages. Moreover, gender-specific logistic regressionmodels adjusted for age, race, residence, literacy, and smokingstatus were created to examine the associations betweendemographic characteristics and health status of the partic-ipants and anemia. Results of the multivariate model arepresented as odds ratios (OR) with their 95% confidenceintervals (95% CI). All analyses used sample weights toaccount for the complex survey design and to report anemiaprevalence nationwide. Statistical analyses were performedusing SPSS, version 17 software (SPSS Inc., Chicago, IL).

    3. Results

    A total of 2,372 subjects with amean age of 71.8 (SD 8.2) yearshad their hemoglobin measured, representing an estimated1.1 million older adults residing in the coastal and AndesMountains regions in Ecuador. As shown in Table 1, theage, area of residency, and race of participants were similarlydistributed by gender. In general, higher proportions ofmen were smokers, literate, and reported good to excellenthealth. In contrast, women had higher rates of obesity,ADL’s limitations, cognitive impairment, and comorbidities.Laboratory data revealed no significant gender differencesregarding CRP, albumin, and ferritin concentrations. How-ever, vitamin B

    12levels were considerably lower among

    men. As shown in Figure 1, women tended to have lower

  • Current Gerontology and Geriatrics Research 3

    Table 1: Demographic and health characteristics of participants in the SABE survey.

    Men(𝑛 = 1, 065)

    Women(𝑛 = 1, 307) 𝑃 value

    Age groups (years), % .48060–69 47.5 46.270–79 31.6 34.5≥80 20.9 19.3

    Race, % .881Indigenous 10.0 11.1Black 3.8 3.4Mestizo 70.6 69.1Mulatto 3.8 3.3White 11.8 13.1

    Area of residency, % .149Urban Andes Mountains 28.3 30.8Urban coast 36.1 37.5Rural Andes Mountains 20.2 20.3Rural coast 15.4 11.4

    Literacy, % 76.7 64.7

  • 4 Current Gerontology and Geriatrics Research

    Hemoglobin (g/dL)MenWomen

    <10

    ≥16

    10.0

    –10.9

    11.0

    –11.9

    12.0

    –12.9

    13.0

    –13.9

    14.0

    –14.9

    15.0

    –15.9

    0.0

    5.0

    10.0

    15.0

    20.0

    25.0

    30.0

    35.0

    40.0

    45.0

    (%)

    Figure 1: Hemoglobin concentrations among older adults inEcuador, SABE II survey.

    hemoglobin concentrations than those in men. For instance,58.5% of women had hemoglobin concentrations less than13 g/dL as compared with 25.2% in men. However, only 2.1%and 1.6% of women andmen had hemoglobin levels less than10 g/dL, respectively.

    Overall, 20.0% of women aged 60 years and olderwere defined as having anemia in Ecuador. Nevertheless,the prevalence of anemia among women was particularlyincreased in blacks and residents from the urban coast.More-over, subjects with certain health conditions such as beingunderweight, chronic kidney disease, hypoalbuminemia, andiron deficiency had significant higher anemia prevalencerates. After adjustment for potential confounders, hypoal-buminemia, chronic kidney disease, being underweight, andiron deficiency were variables independently associated with5.1-, 4.4-, 2.4-, and 2.1-fold increased odds of having anemiaamong older women, respectively (Table 2).

    Anemia was prevalent in 25.2% of older men in Ecuador.Moreover, the prevalence of anemia in men increased withadvancing age and was higher among those residing in theurban coast as compared with residents from other areasof the country. Likewise, subjects with hypoalbuminemia,those diagnosed with cancer, and participants defined ashaving chronic kidney disease, iron deficiency, and lowgrade inflammation had higher prevalence of anemia thanthose who did not. Notably, after adjustment for covariates,older men with hypoalbuminemia and those diagnosed withcancer were 6.8 and 6.5 times more likely to have anemia ascomparedwith thosewithout hypoalbuminemia, respectively(Table 3).

    Figure 2 shows the distribution of nutritional and non-nutritional causes of anemia in older Ecuadorians. Amongnutritional anemias, iron deficiency was the leading causeof anemia in 21.8% of men and 16.3% of women, whereas13.5% of men and 6.6% of women had low vitamin B

    12

    concentrations. Although chronic kidney disease was asso-ciated with increased odds of having anemia in both genders,

    5.2

    13.5

    21.824.2

    31.6

    7.2 6.6

    16.3

    22.7

    35.1

    Chro

    nic k

    idne

    ydi

    seas

    e

    Vita

    min

    B12

    defic

    ienc

    y

    Iron

    defi

    cien

    cy

    Ane

    mia

    of c

    hron

    icdi

    seas

    e

    Low

    gra

    dein

    flam

    mat

    ion

    MenWomen

    0.0

    5.0

    10.0

    15.0

    20.0

    25.0

    30.0

    35.0

    40.0

    (%)

    Figure 2: Selected causes of anemia among older adults in Ecuador,SABE survey.

    only 5.2% of men and 7.2% of women were classified ashaving anemia of chronic kidney disease. Of interest, 24.2%of men and 22.7% of women had ferritin levels > 200 ng/mL,which is highly suggestive of anemia of chronic disease.Of relevance, one-third of older adults with anemia hadevidence of low grade inflammation. Table 4 shows the MCVdistribution among older adults with anemia in Ecuador. Ingeneral, 88% of subjects with anemia had a normal MCVindex. In general, normocytic anemia was predominantlyseen in participants with kidney disease, chronic disease,and low grade inflammation. Moreover, 13.9% of men and14.7% of women with iron deficiency anemia had evidence ofmicrocytosis. On the contrary, a macrocytic morphology waspresent in only 3.1% of subjects with vitamin B

    12deficiency.

    4. Discussion

    The present results indicate that anemia represents a mod-erate public health problem among older adults in Ecuadoraccording to the WHO criteria (prevalence from 20.0% to39.9%) [12]. Overall, one in five subjects aged 60 years andolder was defined as having anemia in Ecuador. Moreover,increased anemia prevalence rates were predominantly seenwith advancing age, in men, black women, and subjectsresiding in the urban coast. Interestingly, the geographicdistribution of anemia found in the present study contrastwith those results previously reported by Cañizares et al. inthe 1980s in which a significant higher prevalence of anemiawas described in the rural areas of the country [7]. It maybe postulated that the increased prevalence of anemia amongolder adults in urban areas of the country may be explainedby changes in the demographic distribution of the populationover time. For instance, the percentage of adults aged 65years and older who lived in the urban areas of the country

  • Current Gerontology and Geriatrics Research 5

    Table 2: Prevalence of anemia among older women in Ecuador.

    Characteristics Crude prevalence OR (95% CI)∗

    Age groups (years), %60–69 17.8 (14.0, 22.2) 1.0070–79 20.5 (16.5, 25.3) 1.17 (1.15, 1.19)≥80 24.1 (18.7, 30.5) 1.37 (1.35, 1.40)

    Race, %Indigenous 19.0 (11.6, 29.7) 0.69 (0.68, 0.71)Black 42.4 (24.4, 62.7) 2.19 (2.12, 2.27)Mestizo 17.8 (14.9, 21.1) 0.66 (0.64, 0.67)Mulatto 24.5 (11.5, 44.6) 0.91 (0.87, 0.94)White 25.3 (18.3, 33.8) 1.00

    Area of residency, %Urban Andes Mountains 18.4 (14.3, 23.4) 1.58 (1.54, 1.62)Urban coast 22.5 (18.3, 27.3) 1.94 (1.89, 1.99)Rural Andes Mountains 20.8 (15.0, 28.1) 1.67 (1.63, 1.72)Rural coast 14.2 (9.1, 21.6) 1.00

    Literacy, %Yes 19.5 (16.6, 22.7) 1.00No 20.8 (16.2, 26.2) 1.09 (1.08, 1.11)

    Smoking, %Current 32.8 (16.7, 54.2) 1.80 (1.75, 1.86)Former 19.6 (13.4, 27.8) 0.99 (0.97, 1.01)Never 19.5 (16.7, 22.5) 1.00

    BMI (kg/m2), %Underweight 34.5 (19.1, 54.1) 2.41 (2.31, 2.51)Normal 28.5 (23.0, 34.6) 2.14 (2.10, 2.18)Overweight 14.9 (11.5, 19.0) 0.96 (0.94, 0.98)Obesity 16.1 (12.2, 21.0) 1.00

    Self-reported health, %Excellent to good 13.1 (9.1, 18.4) 1.00Fair to poor 21.8 (18.8, 25.1) 1.97 (1.93, 2.00)

    ADL’s limitations, %Yes 24.0 (19.2, 29.6) 1.43 (1.41, 1.45)No 18.3 (15.4, 21.5) 1.00

    Cognitive impairment, %Yes 24.3 (18.1, 31.7) 1.44 (1.42, 1.47)No 18.4 (15.6, 21.5) 1.00

    DiabetesYes 22.6 (16.9, 29.4) 1.25 (1.24, 1.27)No 19.3 (16.5, 22.4) 1.00

    Cancer, %Yes 21.0 (10.7, 37.0) 1.15 (1.13, 1.19)No 20.0 (18.1, 23.7) 1.00

    COPD, %Yes 13.0 (6.0, 26.1) 0.54 (0.52, 0.55)No 20.7 (18.1, 23.7) 1.00

    Heart disease, %Yes 22.9 (15.5, 32.5) 1.27 (1.25, 1.29)No 19.4 (16.8, 22.2) 1.00

  • 6 Current Gerontology and Geriatrics Research

    Table 2: Continued.

    Characteristics Crude prevalence OR (95% CI)∗

    Arthritis, %Yes 22.3 (18.1, 27.2) 1.52 (1.50, 1.54)No 18.4 (15.3, 21.8) 1.00

    CRP (mg/L), %

  • Current Gerontology and Geriatrics Research 7

    Table 3: Prevalence of anemia among older men in Ecuador.

    Characteristics Crude prevalence OR (95% CI)∗

    Age groups (years), %60–69 19.5 (15.1, 24.9) 1.0070–79 27.9 (22.4, 34.1) 1.56 (1.54, 1.59)≥80 34.2 (26.8, 42.6) 1.81 (1.78, 1.84)

    Race, %Indigenous 15.6 (8.7, 26.4) 0.63 (0.61, 0.65)Black 26.3 (14.1, 43.9) 1.01 (0.97, 1.05)Mestizo 26.7 (22.6, 31.3) 1.16 (1.14, 1.19)Mulatto 19.5 (9.7, 35.1) 0.65 (0.62, 0.68)White 24.9 (16.0, 36.7) 1.00

    Area of residency, %Urban Andes Mountains 23.3 (17.8, 29.9) 0.94 (0.92, 0.96)Urban coast 30.4 (24.3, 37.2) 1.42 (1.40, 1.45)Rural Andes Mountains 19.3 (14.5, 25.3) 0.86 (0.84, 0.88)Rural coast 24.5 (17.4, 33.5) 1.00

    Literacy, %Yes 23.6 (20.0, 27.7) 1.00No 30.7 (23.9, 38.7) 1.34 (1.32, 1.36)

    Smoking, %Current 24.8 (17.5, 33.8) 1.12 (1.10, 1.14)Former 26.2 (21.5, 31.6) 1.10 (1.08, 1.11)Never 23.6 (18.8, 29.2) 1.00

    BMI (kg/m2), %Underweight 35.0 (18.5, 56.1) 1.55 (1.48, 1.63)Normal 29.5 (24.4, 35.1) 1.49 (1.45, 1.52)Overweight 18.7 (14.3, 24.2) 0.82 (0.80, 0.84)Obesity 19.0 (11.8, 29.3) 1.00

    Self-reported health, %Excellent to good 18.2 (13.6, 23.9) 1.00Fair to poor 28.2 (24.1, 32.7) 1.65 (1.62, 1.67)

    ADL’s limitations, %Yes 36.1 (28.8, 44.2) 1.71 (1.69, 1.74)No 22.0 (18.5, 26.0) 1.00

    Cognitive impairment, %Yes 34.6 (26.0, 44.5) 1.76 (1.72, 1.79)No 21.9 (18.4, 25.8) 1.00

    DiabetesYes 25.6 (17.7, 35.6) 1.04 (1.02, 1.06)No 25.2 (21.7, 29.0) 1.00

    Cancer, %Yes 68.0 (42.8, 85.7) 6.53 (6.27, 6.80)No 24.2 (21.0, 27.8) 1.00

    COPD, %Yes 28.6 (18.4, 41.5) 1.07 (1.04, 1.10)No 24.9 (21.5, 28.6) 1.00

    Heart disease, %Yes 21.9 (14.6, 31.7) 0.65 (0.64, 0.67)No 25.7 (22.2, 29.6) 1.00

    Arthritis,%Yes 29.8 (22.5, 38.3) 1.29 (1.27, 1.31)No 24.0 (20.5, 28.0) 1.00

  • 8 Current Gerontology and Geriatrics Research

    Table 3: Continued.

    Characteristics Crude prevalence OR (95% CI)∗

    CRP (mg/L), %30 23.8 (20.5, 27.4) 1.00≤30 57.3 (37.8, 74.8) 2.98 (2.86, 3.11)

    Albumin (g/dL), %≥3.5 24.4 (21.1, 28.0) 1.00

  • Current Gerontology and Geriatrics Research 9

    of macrocytic anemia. Likewise, Loikas et al. demonstratedin a population-based study among older from Finland thatthe presence of macrocytosis or macrocytic anemia did notincrease the odds of having vitamin B

    12deficiency, which is

    consistent with the present results [34].Interestingly, one-third of older Ecuadorians with anemia

    had evidence of low grade inflammation. Nonnutritionalanemia in older adults has been documented to result froman interaction between an increased inflammatorymilieu andage-related comorbidities. Among the inflammatory mark-ers, IL-6 leads to iron-limited hematopoiesis with increasedhepcidin levels and poor iron incorporation into the devel-oping erythrocytes. In addition, tumor necrosis factor 𝛼,in a different pathway, leads to erythropoietin resistanceof the hematopoietic stem cells, increasing its demand andeventually exceeding the ability of the kidney to maintainadequate levels to sustain normal hemoglobin [15].

    The present study has several limitations that should bementioned. First, because of the cross-sectional study design,the association of anemia with certain demographic andhealth characteristics does not necessarily indicate causation.Second, the evaluation of nutritional and nonnutritionalanemia should be considered preliminary. For instance, ironand vitamin B

    12anemia were defined exclusively according

    to ferritin and vitamin B12

    levels available in the SABEsurvey, respectively. Moreover, other potential causes ofanemia affecting older adults such as folate deficiency andmyelodysplastic syndromes requiring cytogenetic and bonemarrow analyses were not evaluated in the present study [34].Third, most of the participant’s comorbidities and lifestylevariables were self-reported, which may be a source of recallbias. Fourth, the present findings may be only generalizedto older adults residing in the coastal and Andes Mountainsregions of the country. Despite these limitations, the presentstudy reports national estimates of anemia among olderadults.

    In conclusion, anemia is a prevalent condition amongolder adults in Ecuador. Moreover, further research is neededto examine the association between anemia and adversehealth-related outcomes among older Ecuadorians.

    Competing Interests

    The author declares that there is no conflict of interestsregarding the publication of this paper.

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